Pediatric Airway Pediatric Airway EmergenciesEmergencies

ASA Task Force on Management ASA Task Force on Management of the Difficult Airway - Definitions: of the Difficult Airway - Definitions:

difficult airwaydifficult airway = the clinical situation in which a conventionally = the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both. difficulty with tracheal intubation, or both.

difficult mask ventilationdifficult mask ventilation = (1) inability of unassisted = (1) inability of unassisted anesthesiologist to maintain SpO2 > 90% using 100% oxygen and anesthesiologist to maintain SpO2 > 90% using 100% oxygen and positive pressure mask ventilation in a patient whose SpO2 was positive pressure mask ventilation in a patient whose SpO2 was 90% before anesthetic intervention; or (2) inability of the unassisted 90% before anesthetic intervention; or (2) inability of the unassisted anesthesiologist to prevent or reverse signs of inadequate anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation. ventilation during positive pressure mask ventilation.

difficult laryngoscopydifficult laryngoscopy = not being able to see any part of the = not being able to see any part of the vocal vocal cordscords with conventional laryngoscopy with conventional laryngoscopy

difficult intubationdifficult intubation = proper insertion with conventional = proper insertion with conventional laryngoscopy requires either (1) more than three attempts or (2) laryngoscopy requires either (1) more than three attempts or (2) more than ten minutes more than ten minutes

Pediatric PeriOperative Cardiac Pediatric PeriOperative Cardiac Arrest (POCA) RegistryArrest (POCA) Registry

Collects data from 63 large institutions to Collects data from 63 large institutions to correlate perioperative pediatric deaths and correlate perioperative pediatric deaths and anesthesiaanesthesia

The majority are medication related cardiac The majority are medication related cardiac deathsdeaths

1998-2003: Respiratory events increased from 1998-2003: Respiratory events increased from 20 percent to 27 percent. 20 percent to 27 percent.

The most common event leading to cardiac The most common event leading to cardiac arrest in this category was laryngospasm, arrest in this category was laryngospasm, followed by airway obstruction, inadequate followed by airway obstruction, inadequate oxygenation, inadvertent extubation, difficult oxygenation, inadvertent extubation, difficult intubation and bronchospasm. intubation and bronchospasm.

Pediatric Airway EmergenciesPediatric Airway Emergencies

Infrequently encounteredInfrequently encountered StridorStridor History and Physical ExaminationHistory and Physical Examination Multiple EtiologiesMultiple Etiologies

CongenitalCongenital InflammatoryInflammatory IatrogenicIatrogenic NeoplasticNeoplastic TraumaticTraumatic

UrgencyUrgency

Must assess the urgency of the situationMust assess the urgency of the situation Full and frank discussion of the risks with Full and frank discussion of the risks with

the parents (and child if appropriate) the parents (and child if appropriate) including tracheostomy and failure to including tracheostomy and failure to secure the airwaysecure the airway

AnatomyAnatomy Infant larynx: Infant larynx:

-More superior in neck -More superior in neck -Epiglottis shorter, angled -Epiglottis shorter, angled more over glottis more over glottis -Vocal cords slanted: anterior -Vocal cords slanted: anterior commissure more inferiorcommissure more inferior- Vocal process 50% of length - Vocal process 50% of length

-Larynx cone-shaped: -Larynx cone-shaped: narrowest at subglottic cricoid narrowest at subglottic cricoid ring ring -Softer, more pliable: may be -Softer, more pliable: may be gently flexed or rotated gently flexed or rotated anteriorly anteriorly

Infant tongue is largerInfant tongue is larger Head is naturally flexedHead is naturally flexed

HistoryHistory

Assess the urgency of the situationAssess the urgency of the situation Simultaneous History and PhysicalSimultaneous History and Physical

ChokingChoking Aggravating factorsAggravating factors

• Feeding, sleeping, positioningFeeding, sleeping, positioning Throat or neck painThroat or neck pain Birth historyBirth history

• PrenatalPrenatal

Signs of impending respiratory failureSigns of impending respiratory failure Increased respiratory rateIncreased respiratory rate Nasal flaringNasal flaring Use of accessory musclesUse of accessory muscles Cyanosis Cyanosis

Physical ExaminationPhysical ExaminationStridorStridor

StertorStertor Bulky oropharyngeal noiseBulky oropharyngeal noise Inspiratory, expiratory, or bothInspiratory, expiratory, or both

SupraglotticSupraglottic InspiratoryInspiratory

GlotticGlottic Inspiratory progressing to biphasicInspiratory progressing to biphasic

SubglotticSubglottic Inspiratory progressing to biphasicInspiratory progressing to biphasic

TrachealTracheal Expiratory Expiratory

Flexible Laryngoscopy:Flexible Laryngoscopy:

Proper EquipmentProper Equipment Assess Assess

nares/choanaenares/choanae Assess adenoid and Assess adenoid and

lingual tonsillingual tonsil Assess TVC mobilityAssess TVC mobility Assess laryngeal Assess laryngeal

structuresstructures

Radiology:Radiology:

Plain films:Plain films: Chest and airway AP and Chest and airway AP and

laterallateral Expiratory filmsExpiratory films

Airway FlouroscopyAirway Flouroscopy

Quick, noninvasive, and dynamic studyQuick, noninvasive, and dynamic study Supraglottic: 33%Supraglottic: 33% Glottic: 17%Glottic: 17% Subglottic: 80%Subglottic: 80% Tracheal: 73%Tracheal: 73% Bronchial: 80%Bronchial: 80%

Far superior to plain filmsFar superior to plain films Disadv: radiation exposureDisadv: radiation exposure

10 rads (0.1Gy) per 1 minute10 rads (0.1Gy) per 1 minute

MRI/CTMRI/CT

Usually not useful in an acute settingUsually not useful in an acute setting More reliable for evaluating neck masses More reliable for evaluating neck masses

and congenital anomalies of the lower and congenital anomalies of the lower airway and vascular systemairway and vascular system

Treatment OptionsTreatment Options

HelioxHeliox Oral AirwaysOral Airways IntubationIntubation

EndotrachealEndotracheal Laryngeal MaskLaryngeal Mask

TracheostomyTracheostomy EXIT procedureEXIT procedure

HelioxHeliox

Graham’s Law: flow rate Graham’s Law: flow rate is inversely proportional is inversely proportional to the square root of its to the square root of its densitydensity

Helium 7x less dense Helium 7x less dense than Nitrogenthan Nitrogen

Shown to be effective in Shown to be effective in upper airway obstruction, upper airway obstruction, viral croup, viral croup, postextubation stridorpostextubation stridor

HelioxHeliox

Gosz et al:Gosz et al: Immediate positive response in 73% of Immediate positive response in 73% of

patientspatients Average duration of treatment 15min to 384 Average duration of treatment 15min to 384

hours (overall mean of 29.1hrs)hours (overall mean of 29.1hrs) Laryngotracheobronchitis were more likely to Laryngotracheobronchitis were more likely to

respond than other causes. (other causes respond than other causes. (other causes were upper airway obstruction, postextubation were upper airway obstruction, postextubation stridor, congenital heart disease)stridor, congenital heart disease)

Endotracheal IntubationEndotracheal Intubation

Multicenter studyMulticenter study 156 out of 1288 total ED intubations156 out of 1288 total ED intubations

Rapid Sequence Intubation (81%)Rapid Sequence Intubation (81%) Without medications (16%)Without medications (16%) Sedation without neuromuscular blockade (6%)Sedation without neuromuscular blockade (6%)

Overall successful intubationsOverall successful intubations RSI 99%RSI 99% Non RSI 97%Non RSI 97%

Only 1 out of 156 required surgical interventionOnly 1 out of 156 required surgical intervention

Rapid Sequence IntubationRapid Sequence Intubation

Recommended for every emergency Recommended for every emergency intubation involving a child with intact intubation involving a child with intact upper airway reflexes by the Pediatric upper airway reflexes by the Pediatric Emergency Medicine Committee of the Emergency Medicine Committee of the American College of Emergency American College of Emergency PhysiciansPhysicians

Simultaneous administration of a Simultaneous administration of a neuromuscular blockade agent and a neuromuscular blockade agent and a sedativesedative

IntubationIntubation

Rule of 4’s: Age+4/4 = ETT sizeRule of 4’s: Age+4/4 = ETT size Mucosal injury at 25cm of pressure. Therefore, Mucosal injury at 25cm of pressure. Therefore,

always check for leak.always check for leak. Spontaneous ventilation: Spontaneous ventilation:

allows for a limited examination of the dynamics of allows for a limited examination of the dynamics of vocal cord motion. vocal cord motion.

Apneic technique:Apneic technique: Turn to FiO2 100% prior to extubation.Turn to FiO2 100% prior to extubation. 6L O2/min flow via laryngoscope6L O2/min flow via laryngoscope General rule to work apneic in a proportional General rule to work apneic in a proportional

amount of time as reoxygenation.amount of time as reoxygenation.

Laryngeal Mask AirwayLaryngeal Mask Airway

TracheotomyTracheotomy

Cricothyroidotomy is Cricothyroidotomy is difficult b/c of small difficult b/c of small membrane and flexibilitymembrane and flexibility

Early complicationsEarly complications Pneumothorax, bleeding, Pneumothorax, bleeding,

decannulation, obstruction, decannulation, obstruction, infectionsinfections

Late complicationsLate complications Granuloma, decannulation, Granuloma, decannulation,

SGS, tracheocutaneous SGS, tracheocutaneous fistulafistula

EXIT ProcedureEXIT Procedure(ex utero intrapartum treatment)(ex utero intrapartum treatment)

Prenatal diagnosis is Prenatal diagnosis is crucialcrucial Flattened diaphragms, Flattened diaphragms,

polyhydramniospolyhydramnios The head, neck, The head, neck,

thorax, and one arm thorax, and one arm are delivered.are delivered.

Uteroplacental Uteroplacental circulation can be circulation can be maintained for 45-60 maintained for 45-60 minutesminutes

Specific Etiologies of Airway Specific Etiologies of Airway EmergenciesEmergencies

Congenital Neck MassesCongenital Neck Masses Congenital anomaliesCongenital anomalies Syndromic patientsSyndromic patients InflammatoryInflammatory Foreign BodiesForeign Bodies

Congenital Neck MassesCongenital Neck Masses

Dermoid cystsDermoid cysts Mesoderm/ectodermMesoderm/ectoderm

Teratoid cysts and Teratoid cysts and teratomasteratomas All 3 layersAll 3 layers 20% incidence of 20% incidence of

maternal maternal polyhydramniospolyhydramnios

Congenital Neck MassesCongenital Neck Masses

LymphangiomasLymphangiomas Capillary, cavernous, Capillary, cavernous,

cystic typescystic types More airway More airway

obstructive when obstructive when found in the anterior found in the anterior triangletriangle

CHAOSCHAOS(congenital high airway obstruction syndrome)(congenital high airway obstruction syndrome)

Emergent airway management at the time of Emergent airway management at the time of delivery is key for survivaldelivery is key for survival

PrenatallyPrenatally Flattened diaphragms, polyhydramnios, cervical massFlattened diaphragms, polyhydramnios, cervical mass

TEAM MembersTEAM Members Maternal-fetal specialistMaternal-fetal specialist NeonatalogistNeonatalogist AnesthesiologistAnesthesiologist OtolaryngologistOtolaryngologist PatientPatient

LaryngotracheobronchitisLaryngotracheobronchitis(Croup)(Croup)

Parainfluenza type 1Parainfluenza type 1 Generalized mucosal Generalized mucosal

edema of the larynx, edema of the larynx, trachea, bronchitrachea, bronchi

LaryngotracheobronchitisLaryngotracheobronchitisTreatmentTreatment

HumidificationHumidification No scientific data to supportNo scientific data to support May worsen the situationMay worsen the situation

Racemic EpinephrineRacemic Epinephrine Reduces mucosal edema/bronchial relaxationReduces mucosal edema/bronchial relaxation

SteroidsSteroids Systemic vs. InhaledSystemic vs. Inhaled

IntubationIntubation

Bacterial TracheitisBacterial Tracheitis Complication of viral Complication of viral

laryngotracheobronchitislaryngotracheobronchitis Fever, white count, Fever, white count,

respiratory distress respiratory distress following a complicated following a complicated course of croupcourse of croup

Staphylococcus aureusStaphylococcus aureus Endoscopy and Endoscopy and

IntubationIntubation

Acute SupraglottitisAcute Supraglottitis

Mild URI that Mild URI that progresses over a few progresses over a few hours to severe throat hours to severe throat pain, drooling, and pain, drooling, and feverfever

H. influenza, H. influenza, parainfluenzaparainfluenza

TreatmentTreatment IntubationIntubation Empiric AbxEmpiric Abx

Congenital SyndromesCongenital Syndromes

Close embryological development of the Close embryological development of the airways and the craniofacial structuresairways and the craniofacial structures

Early complications are usually more Early complications are usually more profoundprofound

Late complications may be more subtleLate complications may be more subtle

Congenital Syndromes and Airway Congenital Syndromes and Airway EmergenciesEmergencies

Syndromes of facial anomaliesSyndromes of facial anomalies Pierre Robin SequencePierre Robin Sequence Treacher CollinsTreacher Collins Goldenhar/Hemifacial microsomiaGoldenhar/Hemifacial microsomia

Deformities of skull shapeDeformities of skull shape Crouzon’s/Apert’sCrouzon’s/Apert’s PfiefferPfieffer

Pierre Robin SequencePierre Robin Sequence

Micrognathia, relative Micrognathia, relative macroglossia with or macroglossia with or without cleft palatewithout cleft palate

Intubation via the Intubation via the lateral tongue lateral tongue approachapproach

TracheotomyTracheotomy GlossopexyGlossopexy Subperiosteal release Subperiosteal release

of mandibleof mandible

Treacher CollinsTreacher Collins Hypoplastic cheeks, Hypoplastic cheeks,

zygomatic arches, and zygomatic arches, and mandible; mandible;

Microtia with possible Microtia with possible hearing loss; hearing loss;

High arched or cleft palate; High arched or cleft palate; Macrostomia (abnormally Macrostomia (abnormally

large mouth); large mouth); Colobomas; Colobomas; Increased anterior facial Increased anterior facial

height; height; Malocclusion (anterior open Malocclusion (anterior open

bite); bite); Small oral cavity and airway Small oral cavity and airway

with a normal-sized tongue; with a normal-sized tongue;

Goldenhar &Goldenhar &Hemifacial MicrosomiaHemifacial Microsomia

Oculoauricular dysplasiaOculoauricular dysplasia Limited atlanto-occipital extension Limited atlanto-occipital extension

Klippel-Feil Klippel-Feil

Congential fusion of Congential fusion of any 2 of the 7 cervical any 2 of the 7 cervical vertebraevertebrae

Short, immobile neckShort, immobile neck

Crouzon’s/ Apert’sCrouzon’s/ Apert’s

Abnormal closure of the Abnormal closure of the cranial suturescranial sutures

Nasal cavity Nasal cavity Nasophayrngeal Nasophayrngeal stenosis- leads to OSAstenosis- leads to OSA

Associated anomaliesAssociated anomalies SGSSGS Tracheal sleevesTracheal sleeves

TreatmentTreatment Nasal decongestants/ Nasal decongestants/

stentsstents Selective Selective

adenoid/tonsillectomyadenoid/tonsillectomy TracheostomyTracheostomy Midface advancementMidface advancement

MucopolysaccharidosesMucopolysaccharidoses

Hunter’s, Hurler’s, Hunter’s, Hurler’s, Marateaux-LamyMarateaux-Lamy

Progressive infiltration Progressive infiltration of MPS within the of MPS within the airway structuresairway structures

TreatmentTreatment TracheostomyTracheostomy Death by age 10-15Death by age 10-15

Down’s SyndromeDown’s Syndrome

Midface hypoplasia, macroglossia, narrow Midface hypoplasia, macroglossia, narrow nasopharynx, and shortened palate.nasopharynx, and shortened palate.

Immature immune systemImmature immune system Tendency towards obesityTendency towards obesity GERD is very prominentGERD is very prominent Equals a very difficult patient to sedate and still Equals a very difficult patient to sedate and still

maintain an airwaymaintain an airway Longer lifespan of these patients leads to an Longer lifespan of these patients leads to an

increase in the incidence of CHF and pulmonary increase in the incidence of CHF and pulmonary hypertension secondary to OSAhypertension secondary to OSA

Down’s SyndromeDown’s Syndrome Mitchell et al.Mitchell et al. 23 Downs Patients23 Downs Patients

48% OSA48% OSA 43% Laryngomalacia43% Laryngomalacia

Systemic comorbiditiesSystemic comorbidities 61% GERD61% GERD

Cause of Upper airway obstruction is age relatedCause of Upper airway obstruction is age related <2yrs old: laryngomalacia is most common cause<2yrs old: laryngomalacia is most common cause

• Age dependent progression to OSAAge dependent progression to OSA >2yrs old: OSA is most common cause>2yrs old: OSA is most common cause

• Delay in diagnosis is common because symptoms overlapDelay in diagnosis is common because symptoms overlap

Down’s SyndromeDown’s Syndrome Jacobs et al.Jacobs et al. 55 of 71 patients underwent upper airway surgery (all had DL/B at 55 of 71 patients underwent upper airway surgery (all had DL/B at

the same time)the same time) 44 T&A with pillar plication, 4 UPPP44 T&A with pillar plication, 4 UPPP

Overall:Overall: 76% had significant or complete relief 76% had significant or complete relief 24% had moderate or severe residual symptoms24% had moderate or severe residual symptoms

Failures:Failures: Greater number of obstructive sitesGreater number of obstructive sites

• Laryngotracheal stenosis (23% of failures)Laryngotracheal stenosis (23% of failures)• Tongue baseTongue base

More severe UAOMore severe UAO Recommendations:Recommendations:

Comprehensive preoperative airway evaluationComprehensive preoperative airway evaluation Tailor the surgical procedure for the site of obstructionTailor the surgical procedure for the site of obstruction Close follow up for failuresClose follow up for failures

Choanal AtresiaChoanal Atresia

Failure of the breakdown Failure of the breakdown of the buccopharyngel of the buccopharyngel membranemembrane

McGovern Nipple and McGovern Nipple and nasogastric feedingnasogastric feeding

CHARGE associationCHARGE association ColobomasColobomas Heart abnormalitiesHeart abnormalities Renal anomaliesRenal anomalies Genital abnormalitiesGenital abnormalities Ear abnormalitiesEar abnormalities

Foreign BodiesForeign Bodies

2-4year olds2-4year olds Acute episode of choking/gaggingAcute episode of choking/gagging Triad of acute wheeze, cough and Triad of acute wheeze, cough and

unilateral diminished sounds only in 50%unilateral diminished sounds only in 50% 5-40% of patients manifest no obvious 5-40% of patients manifest no obvious

signssigns

Foreign BodiesForeign Bodies

Severity is determined by Severity is determined by complete vs partial complete vs partial obstructionobstruction

Peanuts are most Peanuts are most commoncommon

Right mainstemRight mainstem Larger diameterLarger diameter More airflow than leftMore airflow than left Narrow angle of Narrow angle of

divergencedivergence Carina sits on the left sideCarina sits on the left side

Foreign BodiesForeign Bodies

Foreign BodiesForeign Bodies

Plain radiography:Plain radiography: 25% of bronchial lesions and >50% of 25% of bronchial lesions and >50% of

tracheal lesions do not show uptracheal lesions do not show up Airway Flouroscopy:Airway Flouroscopy:

Above the carina: 32-40%Above the carina: 32-40% Below the carina: 80-90%Below the carina: 80-90%

DL/B:DL/B: Gold StandardGold Standard

Airway Foreign BodiesAirway Foreign Bodies